Early and Late Macular Changes After the Inverted Internal Limiting Membrane Flap Technique for a Full-Thickness Macular Hole

Abstract

Purpose: To describe the anatomic evolution of full-thickness macular hole closure after the inverted internal limiting membrane (ILM) flap technique. Methods: A retrospective review of 39 eyes (38 patients) with a full-thickness macular hole treated with the inverted ILM flap technique was performed. Ophthalmic examinations and imaging were performed preoperatively and postoperatively. Results: Macular changes in the early postoperative period included flap closure (15.4%), U-shaped closure (17.9%), V-shaped closure (33.3%), W-shaped closure (28.2%), gap closure (2.6%), and gap open (2.6%). Flap closure was associated with low myopia and shorter axial length (P < 0.05). Two types of flap closure were observed. Type 1 was characterized by gap opening with an ILM cap, followed by a thickened ILM band drawing the edges of the macular hole closer with subsequent external limiting membrane formation; Type 2 was characterized by gap closure with an ILM cap, followed by gliotic proliferation filling the gap. Flap closure configuration disappeared within 4 months postoperatively. At the last follow-up, foveal contours were U-shaped closure (25.6%), V-shaped closure (35.9%), W-shaped closure (35.9%), and gap open (2.6%). Conclusion: Two types of flap closure were observed in the early postoperative period. Several patterns of the foveal contour were observed in the late period. The presence of the ILM flap predicts eventual hole closure. These findings require confirmation and further elucidation of their possible clinical significance.

Flap-Related Complications Following Temporal Inverted Internal Limiting Membrane Flap for Macular Hole Repair

“… 1 , 5 , 8 , 11 Bonińska et al 5 showed that flap closure persisted in only one-third of the eyes at the end of 1 month, and completely disappeared and turned into other closure patterns at the end of the 3 months. Tsui and Yang 12 reported the mean time to disappearance of the flap closure as 2 months, which was similar to case 1 in this report. However, in some eyes, the ILM flap may persist much longer while MH closure takes place.…”

Macular Morphology After Macular Hole Surgery Using the Inverted Internal Limiting Membrane Flap Technique

“…The inferior/superior PRT ratio was also higher in the D and P groups. Boninska et al 16 were the first to report that 44.3% of cases had hyperreflective remnants on the retinal surface, and Tsui et al 17 reported this number as 65.8%. The ILM flap size measured by Tsui et al was two disc diameters larger than that of Boninska et al, and it was inferred that the size was the cause of the difference in proportion.…”

Fluid Gas Exchange for Flap Closure of Idiopathic Macular Hole

“…(5/16), higher than previous studies and all the cases at the status of flap closure remained within 4 months. 11 In our study, 6.99% of the eyes showed ILM flap closure at 1 month postoperatively after the superior inverted ILM flap technique for idiopathic MHs. However, all flap closures, including those performed in-office FGE progressed to complete MH closure within 12 months postoperatively.…”

“…We further found that the mean time required to connect the two ends of macular structures and achieve complete MH closure was 3.60 (range, 1-8 months) months after FGE in the group that underwent FGE. Thus, all eyes in the group that receive FGE required a mean time of 7 (561 / 836 and 603 /884μm), Michalewska et al 6 (544/894μm) and Tsui et al 11 (non-high myopia group, 738/1582μm). An MH with a larger minimal diameter may show a higher rate of flap closure after inverted ILM flap techniques.…”

“…10 However, the intervals between the phases of flap closure varied across previous studies, ranging from several months to even more than one year without vision improvement after the inverted ILM flap. 6,7,11 No further treatment has been proposed until complete healing of all layers of macular structures themselves for vision recovery. In view of the findings of Shiod et al, our study used simple in-office fluid-gas exchange (FGE) for long-term flap closure to complete MH closure, reconnection of the two ends of the macular structures, in a prolonged dry environment.…”